Pre-Examination Form
Fill this form out prior to your pet's appointment. It's always helpful if you can do so at least 24 hours prior to the appointment. Thanks for letting us take care of your pet!
Owner's Name
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First Name
Last Name
Best Contact Phone
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Area Code
Phone Number
Email Address
example@example.com
Is this your pet's first visit with us?
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Yes. This is my first visit to your office as well.
Yes. I have been to your office with other pets.
No.
Has your address changed since your last visit?
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Yes
No
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Co-Owner's Name
Relationship to co-owner
Spouse
Significant Other
Family Member
Friend
Co-owner Phone Number
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Area Code
Phone Number
How did you find us?
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Website
Internet search
Friend or family
Other veterinary office or business
Other
Which website?
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What search term did you use?
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Please provide us with their name so we can send them a thank you with clinic credit!
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Name of veterinary office or business
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Please explain
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Pet's Name
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Birth date or age
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Species
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Cat
Dog
Other
Breed(s)
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Color(s) / Marking(s)
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Sex
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Female
Male
Unknown
Spayed or neutered
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Yes
No
Uncertain
Would you like more information on spaying or neutering your pet?
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Yes
No - My pet is scheduled or will be scheduled to be spayed / neutered at another facility
No - I do not intend on spaying / neutering my pet and am aware of the serious health and behavior risks
Anything you'd like us to know to make your pet's visit stress-free?
e.g. prefers females, doesn't like feet touched, owner protective, does not do well around dogs, etc.
It's important for us to obtain your pet's full medical history prior to their appointment. We are happy to reach out to their previous veterinary office(s).
Please provide us with the following:
Previous practice(s) name
City and state
Previous practice phone number (if available)
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Area Code
Phone Number
Pet first and last name (if different than names provided)
Are there other pets in your household you'd like us to request history for? If yes, please list name(s) and species below:
For pets adopted from shelters/rescue organizations or new puppy/kitten vaccine info from breeders, you can upload a copy of their medical history here:
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If you don't currently have access to this, please be sure to send to the office at least 24 hours prior to your pet's appointment
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Appointment Date
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Month
-
Day
Year
Date
How would you like your pet seen?
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I would like to be present for my pet's exam.
I have arranged to drop my pet off (not available for any pets actively coughing, sneezing, or displaying other signs of upper respiratory infections).
Drop Off Authorization. I understand there is a $39 suite fee any time my pet stays with Northwest Veterinary Hospital unless otherwise indicated. In the event that my pet becomes ill while in their care, I authorize Northwest Veterinary Hospital to perform any procedures necessary for treating and maintaining my pet's health and well being. I understand the staff will stabilize my pet in an emergency and then try to reach me or alternative contact as soon as possible for further treatment. While I expect all procedures to be performed to the best of the staff's abilities, I realize the hospital makes no guarantee or warranty regarding the results. I understand there is a risk to many procedures, including anesthesia. If my pet should injure itself, escape, fail to eat, become ill, or die, I do not hold Northwest Veterinary Hospital and its employees responsible. Payment is required at the time of pick up.
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I agree to the drop off authorization
Drop Off Contact Notice: We may call you from our office phone or a blocked number. Please be sure to answer or call back immediately so our doctors and technicians can discuss exam findings and go over necessary and recommended treatments. If we are unable to speak with you in a timely manner, we may not be able to perform all necessary treatments while your pet is here. Provide the best contact phone number(s) while your pet stays with us.
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Main reason for your pet's visit
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Annual or Semi-Annual Wellness Exam (with or without vaccines and lab work)
New Pet to Household (including puppies and kittens)
Recheck Examination or lab work
Gastrointestinal Issues (vomiting, diarrhea, constipation, etc)
Skin / Ear concerns
Growth or Mass
Eye Concerns
Urinary Concerns
Mobility Concerns (limping, painful, etc)
Upper Respiratory Symptoms (coughing, sneezing, runny eyes)
Other Reason
Please note: If you have multiple concerns you'd like addressed at your pet's appointment, consider your main 2-3 goals for your pet's visit so we have adequate time to address them.
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Wellness Exam
We recommend all pets stay on heartworm, intestinal parasite (usually included in heartworm medications), flea and tick medication year round. What heartworm, flea, and tick preventative(s) is your pet on? Do they get their doses consistently year-round?
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For dogs, we carry ProHeart 12, NexGard Plus, Heartgard Plus, NexGard, and Advantage Multi. For cats, we carry Advantage Multi. All our preventatives are guaranteed by their manufacturers and most have rebates available. Would you like to know more about these products?
Yes!
Nah. Not my first rodeo with these products.
Do you need more flea / heartworm prevention at your pet's appointment? If yes, let us know which preventative(s) and how many you'd like.
Any known allergies?
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Current diet (include name, wet or dry, frequency of feeding, amount fed at each meal)
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Is your pet on any medications (including medications given as needed)?
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Yes
No
Current Medications (Please include dose and frequency)
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For Cats Only: Does your cat go outside or come into contact with other cats that do?
Yes
No
Any Injuries in past 30 days?
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Yes
No
If yes, please describe.
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Appetite, water consumption, defecation, urination normal?
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Yes
No
If no, please describe
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Any other concerns?
Please note if your pet's appointment is for annual wellness with or without vaccines and you have other health concerns, we may need to see them at a separate appointment so we can address all of their needs comprehensively. If you're pet is ill, we may need to forego updating vaccines at this appointment.
Annual appointment preparation: Bring your pet in fasted of food* for 12 hours (fine to give water). If your pet is on medication, they can still take this with a small snack, not a full meal. If they defecate within 12 hours of the appointment, please bring a marble-sized sample in a baggie to the appointment. If older than 2 hours, keep refrigerated. Please try to keep your pet from urinating for several hours before their appointment so the doctor can palpate your pet's bladder and we can catch a sample if needed.
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I have read and understand the preparation recommended for my pet's appointment or will reach out the office with any questions.
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New Pet Exam
How did you acquire your new furry friend?
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Shelter, pet rescue group, breeder, found pet
How long has your pet been in your home?
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Current diet (please include name, wet or dry, frequency of feeding, amount fed at each meal)
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We recommend all pets start on heartworm, intestinal parasite, flea and tick medication at 6 weeks of age and remain on their preventative(s) year round. Is your pet on parasite prevention?
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Yes
No
Unsure
What is most important to you about your pet's parasite prevention (select all that apply):
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Heartworm prevention
Flea prevention
Intestinal parasite prevention
Tick prevention
Taste
Topical application preferred
Cost
Other
Which preventative(s)? How frequently are they given?
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Is your pet on any medications (included medications given as needed)
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Yes
No
Current medications (please include dose and frequency)
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Please select anything you'd like more information on today:
Spaying / Neutering
Microchip
Vaccine schedule
Heartworm disease
Diet
Integration with other pets in household
Other
Any other concerns?
Please note if your new pet's appointment is for wellness and you have other health concerns, we may need to see them at a separate appointment so we can address all of their needs comprehensively.
My pet is:
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Less than 12 months old
1 year or older
We recommend comprehensive lab work for your pet. We recommend you bring your pet in fasted of food* for 12 hours (fine to give water). If your pet is on medication, they can still take this with a small snack, not a full meal. If they defecate within 12 hours of the appointment, please bring a marble-sized sample in a baggie to the appointment. If older than 2 hours, keep refrigerated. Please try to keep your pet from urinating for several hours before their appointment so the doctor can palpate your pet's bladder and we can catch a sample if needed.
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I have read and understand the preparation recommended for my pet's appointment or will reach out to the office with any questions.
We recommend testing for intestinal parasites for every new patient (even if they have received de-worming treatment). Intestinal parasites can be transmittable to other animals and even humans. To make their experience more positive, you can bring a sample with you the appointment. If they defecate within 12 hours of the appointment, please bring at least a marble-sized sample in a baggie to the appointment. If older than 2 hours, keep refrigerated.
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I have read and understand the preparation recommended for my pet's appointment or will reach out to the office with any questions.
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Recheck Exam or Lab Work
Any changes since your last visit or communication with the office? If so, describe.
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Were any medications or diets prescribed to address the original concern?
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Yes
No
When was the medication(s) last given?
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What changes have you seen, if any?
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Anything else you would like us to know?
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Gastrointestinal Exam
Main reason for visit
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When did symptoms start?
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How often? Last episode?
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Please describe form, color, and if any blood or mucous present
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Form examples: undigested food, bile, liquid, soft but formed, cow paddy, formed and firm
What diet is your pet on (including treats)? How much and how often?
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For diarrhea and constipation, any straining?
Is your pet on any medications (including medications given as needed)?
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Yes
No
Current Medications (Please include name, dose and frequency)
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Any recent diet changes? Human food? New treats?
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Any possible or known toxin, plant or medication exposure?
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Eaten anything unusual lately (bedding, rocks, sticks, trash, clothing)?
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Appetite is
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Normal / No change
Decreased
Increased
By how much?
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Water intake is
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Normal / No change
Decreased
Increased
By how much?
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Do any other pets in your house have GI issues? If yes, please describe.
Anything else you would like us to know?
For diarrhea, we will likely check for intestinal parasites. If your pet defecates within 12 hours of the appointment, please bag at least a marble-sized portion. If older than 2 hours, keep refrigerated until your pet's appointment.
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I understand
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Skin / Ear Exam
Main reason for visit
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When did symptoms start?
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Seeing scratching, licking, head shaking? If so, where and how often?
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Any discharge or odor? If yes, please describe.
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Any hair loss? If so, where.
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Has your pet been groomed, bathed or swimming lately?
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Is your pet on any medications (including medications given as needed)?
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Yes
No
Current Medications (Please include dose and frequency)
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Current Diet
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Any known allergies?
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Any history of this issue occurring previously? If so when and how often?
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Anything else you would like us to know?
Photos of affected sites can be very helpful. Please upload if available.
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Growth / Mass Exam
Main reason for today's visit
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When was this noticed?
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How many growths / masses?
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1
2
3
4 or more *Contact the hospital as additional time may be needed for your pet's appointment
Other
Location(s)?
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Does it seem tender?
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Has it changed in size, shape or color since first noticed?
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Any discharge or odor? If yes, please describe.
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Chewing or licking at area(s)?
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Anything else you'd like us to know?
Photos of affected sites can be very helpful. Please upload if available.
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Eye(s) Exam
Main reason for visit?
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When did it start?
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If your pet is squinting and does not have an appointment today, please contact the office directly.
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My pet is not squinting
My pet is squinting and has an appointment today
Any discharge seen? If so, color and appearance?
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Is your pet rubbing or pawing at their eyes?
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Any known trauma? if yes, please describe.
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Anything else you'd like us to know?
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Urinary Exam
Main reason for visit
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When did this start and how often?
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Is your pet straining to urinate?*
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*Please note this may be an emergency, especially for male cats. Contact the office directly if you notice straining.
Leaking urine while resting / sleeping?
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Color / odor of urine? Any blood noticed?
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Urinating inside house or outside of litter box?
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Yes
No
Unsure
Is your pet urinating in the same place(s)?
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History of urinary tract infections? Crystals or stones?
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Yes
No
Unsure
Current Diet (include name, dry or wet, amount fed and frequency)
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Any change to H20 intake?
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Yes
No
Unsure
Increased or decreased by how much?
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Anything else you'd like us to know?
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Mobility Exam
Main reason for visit
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When did this start and how often?
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Any changes since first noticed? if yes, please describe.
Any known trauma? If yes, please describe.
Is your pet favoring a limb?
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Yes
No
Which limb? Select all that apply.
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Front Right (Passenger side)
Rear Right
Front Left (Driver's side)
Rear Left
Is your pet putting any weight on the limb?
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Does it seem to worsen after periods of activity or inactivity?
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Reluctant to go up or downstairs, jump on or off furniture?
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We recommend limiting your pet's activity until they can be examine. Leash walks only, isolate to a room or crate if unable to directly observe, carry up and down stairs if possible.
Any crying or vocalizing? If so, when?
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On any medications? Joint supplements? NSAIDs? Any human medication?
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Instructions, dosage, amount and frequency given, when last given
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Any other concerns?
Please upload if you have any videos of your pet displaying symptoms.
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Coughing / Sneezing / Upper Respiratory Exam
Main reason for visit
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When did it start?
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How often are you seeing symptoms?
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Has your pet had this issue before? If so, how often and when was the most recent episode.
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Are you seeing any discharge? If so, where from? Color?
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Has your pet been boarded, groomed, in public parks, or recently adopted?
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Is your pet on any medications (including medications given as needed)?
Yes
No
Current Medications (Please include dose and frequency)
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Any changes to appetite, water intake, urination or defecation? If yes, please describe.
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Anything else you'd like us to know?
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Main reason for visit
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When did this start and how often?
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Any changes since first noticed? If so, describe.
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Current Diet (include name, dry or wet, amount fed and frequency)
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Is your pet on any medications (including medications given as needed)?
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Yes
No
Current Medications (Please include dose and frequency)
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Any changes to appetite, water intake, urination or defecation? If yes, please describe.
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Anything else you'd like us to know?
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Privacy and Medical Records release
Section 801.353 of the Texas Veterinary Licensing Act protects your privacy by prohibiting disclosure of your pet(s) health care records (including rabies and other immunizations) without our specific authorization.
I give Northwest Veterinary Hospital permission to release information concerning the veterinary care for my pet(s):
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Yes
No
I give Northwest Veterinary Hospital permission to use my pet(s) names and pictures for display, public relations and marketing.
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Yes
No
By signing this form, I acknowledge I have read and agree to the missed appointment policy
Signature
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Print Name
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